Excursions in Medical History: Sartorial Musings

Why do we wear scrubs?

Before Lister, surgery was conducted in operating theaters with surgeons wearing their street clothes. Wikipedia tells us, "In contrast to today's concept of surgery as a profession that emphasizes cleanliness and conscientiousness, at the beginning of the 20th century the mark of a busy and successful surgeon was the profusion of blood and fluids on his clothes." Packing gauze consisted of the discarded stuff from cotton mill floors. Yuck!

By World War II, though, sterilized instruments, antiseptic drapes, and surgical gowns had come into common use. They were white at first, but along with the white walls the attire promoted glare and eye strain, so green began to be used for contrast, and later various shades of blue and grey. The outfits used to be called "surgical greens" but are now called "scrubs" presumably because of their use in "scrubbed" areas.

It's nice not to have to worry about what to wear at work every day, and to have the way you look be of minimal importance. But it can be tedious to mill about in a sea of blue or grey or green where sometimes people don't recognize you in the locker room because you actually have HAIR (messy, of course, at the end of the day) and a FACE (now with discernible expressions). There's not a lot of opportunity to express one's individuality amid all the blue pajamas. Yet it happens - through hats.

Some people go for color and a snug-bonnet look.

Others for poofiness and cheerful designs. For the most fun-filled ones, children's hospitals are unbeatable.  I once knew a pediatric anesthesiologist named Bob who wore - you guessed it - Sponge Bob hats every day.  Cute.

Some express pride in their personal background or heritage.

And others remind us of the non-medical hobbies near and dear to their hearts.  This surgeon, a total sweetheart among surgeons, loves to fly planes...

The World Series sees a host of Red Sox hats and the occasional Yankees covering. The one time I get into the spirit of a season is in the winter, when I wear my Christmasy snowman hats. I've been a "color" person in the past, too, but lately I've been pretty lazy and just wearing the standard issue ones at the hospital. Maybe I should go back to my deep purple, or my bright teal, instead of succumbing to the un-creative convenience of the ones out of the box...

Check out Terry's enjoyable post, "Ode to Hat Hair," over at Counting Sheep.

Ful

My friend Thaer, who just married my dear college friend Sheila, prepared some wonderful Ful for us this weekend while we were all getting some lakeside R&R before a busy end-of-July. I think I'm going to have to do a more in-depth exploration of Palestinian cuisine! (There are versions of the dish in many Arabic-speaking cultures, as well as Turkey, I think - sample recipes here and here.)

Ful

• Sauté 3 minced garlic cloves in a couple of tablespoons of oil. Do not allow garlic to brown.
• Add 1 can fava beans plus 1/2 of the liquid from the can.
• Stir well and season with salt to taste.
• Cover and simmer 5-10 min.
• Chop 1/2 of a medium onion and 1/2 of a medium tomato.
  Remove beans from heat (you can mash them up a little first) and place in a bowl.
• Add onions and tomato and 2-4 Tb extra virgin olive oil.
  
• Optional: add a couple of tablespoons of tahini sauce pre-mixed with a little hot water, and a few squirts of lime juice
  
• Eat with flatbread, crackers, rice, regular bread, or other accompaniment of choice.

The more I get to know Thaer, the more I admire him. He has a kind smile and a ready laugh. He has a playful sense of humor. He is gentle and affectionate with his wife and sweet with our kids. He's an incredibly talented artist. He has dance moves I've never seen before, and a wonderful sense of rhythm. All that and he cooks, cleans, and does dishes and laundry! But what I find truly inspiring about him is that despite his past sufferings, he isn't cynical, bitter, resentful, or wallowing in the victim role. In fact, I know few people with a greater capacity for joy and gratitude. I've seen people who have had WAY more comfortable lives complain MUCH more about their lot - me right up there with them, I'm sorry to say. What's up with that?

Tales from Saint Boonie's: Songs in the O.R.

There are a few things that bring the docs and nurses at St. Boonie's together. The Red Sox. Food and drink. On occasion, certain movies or songs or T.V. shows.

And, escape fantasies.

As the nurse preps the abdomen for surgery, and the surgeon gowns up, and the anesthesiologist adjusts ventilator settings, sometimes they can be heard sharing the latest plan: leave St. Boonie's to become a mystery shopper or marry a millionaire; do locum tenens work and freelance for travel or food magazines between jobs; quit medicine entirely after winning the lotto. The same conversation comes back over and over again in different incarnations.

But do we hate our jobs so much that we're constantly joking around about means of escape? Is being in health care so completely odious that we just abhor getting out of bed every morning?

Well, no. I think we all dislike the annoyances, large and small, like workplace politics, and call, and the daily dose of obnoxious behavior from some unforeseen source. But we "have it pretty good" at St. Boonie's. It's a village, a family, and none of us would want to lose that kind of community life at work.

And the work itself has irreplaceable rewards - not always obvious or easy to appreciate. But if we keep ourselves mindful enough, they're there to remind us of why we chose this path in the first place.

Take old Sully Carlton. Sully had a cardiac defibrillator implanted into his body to deliver an electric shock in the event of a potentially fatal disturbance in heart rhythm. He was having dinner one night when the thing went off and jolted him right out of his plate of pot roast. He came to St. Boonie's so the cardiologist could test and adjust the device.

As the PACU nurse and I were putting monitors on him, as well as pads for an external defibrillator and an oxygen mask, he said to us, "You girls fussing over me like this make me feel like I'm important or something."

We both smiled at him and said something like, "Of COURSE you're important! In fact, at this very moment, there's no one more important to us than you."

Sully replied, "I think this is the only time anyone's going to feel that way about me." He sounded matter-of-fact, not self-pitying, but there was a hint of loneliness in his voice and eyes. I looked into his eyes, trying to find something to say. I couldn't think of anything, so I gave his arm an affectionate squeeze instead.

"You ready?" I said to the cardiologist.

I gave Sully the anesthetic through his IV, then started to assist his breaths with a bag-mask ventilator.

"I'm going to induce V-fib now," the cardiologist announced. That's that potentially fatal heart rhythm - the one we don't usually like to see, because it KILLS people.

"Great," I said, a little sardonically. "I can't wait."

The testing procedure went completely smoothly. Sully's implanted defibrillator fired and corrected the abnormal rhythm without a hitch. Five minutes later Sully was back with us. The drug I had given him sometimes gives people a very refreshed, almost euphoric feeling, and sometimes removes enough inhibitions to allow for some fairly intimate disclosures. Sully awoke thanking us and thinking about his late wife.

"I took care of her in the end, you know," he said, his speech still a little slurred. "I cleaned her up when she couldn't do for herself. I combed her hair."

We murmured words of admiration, of praise. Then he dozed off. Sully was a good guy. I wondered if in his dreams he and his wife were young and in love and unencumbered by things like defibrillators and terminal illness.

Then there was little Cassie Molloy. Cassie was a cute, curious, sociable little girl with honey-colored hair. She reminded me of Abigail Breslin's character in the movie Little Miss Sunshine. She had broken her forearm falling off her scooter. The orthopedic surgeon, Dr. Warbucks, was a pleasant, portly man with a poker-faced sense of humor. He sat in the corner of the O.R. waiting as we placed monitors on Cassie.

She began to get a little tearful and said she wanted her Grammy. I tried to console her and asked her if she knew any good songs.

"She likes Hush Little Baby," the nurse helping me said. We started singing to Cassie.

"Hush little baby, don't say a word; Momma's gonna buy you a mocking bird..."

We continued while I searched in vain for a blood pressure cuff of the correct size. Another nurse left the room to retrieve one. I gave Cassie oxygen with a well-cushioned face mask. She asked for Rockabye Baby.

"Rockabye, Baby on the tree top; when the wind blows, the cradle will rock..."

Still no cuff. We started on some songs from The Sound of Music. "Raindrops on roses and whiskers on kittens; bright copper kettles and warm woolen mittens..."

Finally the correct blood pressure cuff arrived, and we put it on. I turned on some nitrous oxide and asked Cassie to pretend there was a little birthday candle inside her oxygen mask that needed to be blown out. "Big breath now, sweetpea. Blow that birthday candle out. Brown paper packages tied up with strings...These are a few of my favorite things..."

Cassie was calmer now, her breathing more relaxed. "How are you doing, sweetheart? Give me one more nice deep breath, that's a girl. Edelweiss, Edelweiss, ever morning you greet me..."

I began pushing the milky white drug into her IV. Her eyes began to show the familiar movements of a child entering an anesthetized state. I started to assist her breathing. Everything was going as smoothly as I'd hoped.

As I gave Cassie the anesthetic I heard a sound coming from the corner of the room. A baritone voice, soft at first, almost distant, singing as I inserted the laryngeal mask airway.

"Perhaps I had a had a wicked childhood. Perhaps I had a miserable youth."

Then, a little louder, "But somewhere in my wicked, miserable past there must have been a moment of truth." Dr. Warbucks, though feeling a little impatient over the delay with the blood pressure cuff, had gotten into the Rodgers and Hammerstein spirit.

As I secured the LMA into place, he stood up, put on his x-ray apron, and belted in my direction, "For here you are, standing there, loving me, whether or not you should!"

So I replied, and we finished together, "So somewhere in my youth or childhood, I must have done something good."

Later in the recovery room, after a smooth awakening, Cassie was sitting up in bed chatting happily with the nurse, totally comfortable and in good spirits. Dr. Warbucks had given her a bright pink cast for her arm. "Hi, sweetie," I said, checking in on her. She gave me a big smile. I asked how she was feeling, and if she remembered anything. She said she dreamed she was wearing a beautiful dress like Cinderella at the ball. And she said, "I remember you sang me a song."

Sigh. Okay. The lotto can wait.

Why The O.R. is NOT a "Meat Market," Grey's Anatomy Notwithstanding; and, Looking a Patient in the Mouth: What's That About?

(West Side Story music intro blares - tararararum-tum-tum ta ra-ra):

"I feel pretty,

Oh, so pretty,

I feel pretty and witty and bright!

And I pity

Any girl who isn't me tonight..."

***

Now for some more prettiness.

I've been asked time and again by patients why I examine the interiors of their mouths. "What'd you do that for?" They say with puzzled, sometimes curious, expressions.

I'm doing a physical exam of the airway to determine its Mallampati Class - based on a classification system that allows anesthesiologists to assess and document visible landmarks and to communicate those findings with other anesthesiologists.

A "good" Mallampati class (Class I), however, does not always portend an easy intubation, nor is a disfavorable one (Class III) always a harbinger of airway trouble. I use the Mallampati classification in conjunction with other physical features that over the years have seemed to point to ease or difficulty of mask ventilating or intubating a particular airway.

I get a general idea of the amount of soft tissue around the face and neck as well as the quantity of facial hair.

I look at the size of the jaw - particularly the "thyromental distance" from, roughly, the tip of the chin to the neck, I specifically try to evaluate how "well" a person's tongue fits into the jaw interior, or the floor of the mouth, because that's where I'll be trying to tuck it with my laryngoscope when I put the breathing tube in.

I look at whether the front of the chin lies slightly in front of or behind the front teeth when examining someone from the side. I also try to get a general idea of the shape of someone's chin-to-neck profile.

I try to pick up on any unusual features like a high-arched palate, very prominent structures, loose teeth, etc.

When I was in school and thought I would be a medical geneticist, I studied pictures in a book entitled Smith's Recognizable Patterns of Human Malformation. It's at times an alarming and saddening volume. After getting to know that book fairly well I started to see genetic syndromes all around me, in people walking down the street or corridor, much as medical students learning about pathologic symptoms suddenly start to think they're coming down with every disease in the pathophysiology textbook.

Now I've narrowed down my scanning bias to four things that I can't help but notice about people almost immediately:

Good veins,

Bad veins,

Favorable airway (ok, I'll admit it - I just wanted an excuse to put Prince Caspian on this blog somewhere),

and

Scary airway.

I think it's interesting how different meanings can be assigned to external appearance. For some it's a suggestion of ethnic heritage, and all the assumptions, correct and incorrect, that can accompany the impression. For others it's a potential mating signal. For anesthesiologists in work mode, it comes down to the very basics, the crucial stuff: does what I see give me clues about whether I can protect your airway, and thus your very life? It may be a very narrow scope through which to focus on and view the world, but for those few hours when we're on duty, it's an important one.

So open wide, please. It helps us do our job.

Excursions in Medical History: In Memoriam

Michael Ellis DeBakey

September 7, 1908 - July 11, 2008

How to begin to honor this true medical pioneer, who was cited as a "Living Legend" by the Library of Congress in 2000?

DeBakey. I hear his name almost every day. He developed over 70 medical instruments. Every time I hear a surgeon ask the tech for "DeBakeys" - forceps, or perhaps clamps or a needle holder - I think of him.

He was born Michel Dabaghi to Lebanese parents in Lake Charles, Louisiana. At the age of 23 he invented the roller pump which contributed to the development of bypass machines that allow for heart bypass surgery. He was among the first to perform coronary artery bypass surgery, as well as to develop an artificial heart, a left ventricular assist device to bridge patients waiting for a heart transplant, a surgical camera stand to allow surgery to be captured on film, MASH units, and vascular grafts. He pioneered clinical assessment tools and procedures, including the first carotid endarterectomy in 1953. He developed the DeBakey Classification to describe aortic dissection - a condition which took the lives of Lucille Ball, John Ritter, and Rent composer Jonathan Larson - and the Debakey Procedure to correct it. In February of 2006 he became the oldest person, then 97, to undergo and survive his own procedure. Done by a surgeon HE trained.

The list of awards and honors he has won is too long to post but can be found here. Among them was the Congressional Gold Medal, which placed him in the company of Edison, Salk, Washington, and Churchill. He operated on Hollywood stars, heads of state, and ordinary folks who meant more to their families than any performer or politician ever could. He trained THOUSANDS of surgeons, passing on a legacy of good work to future generations and countless patients. What a life!

By many accounts, he was TOUGH. A Nova documentary entitled "Electric Heart" gives us a brief glimpse into what it was like to train under him:


NARRATOR: Dr. Michael DeBakey is a pioneer of the artificial heart. In the 1960s he was one of a handful of leading heart surgeons. Known as the Texas Tornado, he both inspired and terrified those around him.

MICHAEL DeBAKEY [film footage]: What do you mean, "it's not flushing"? No, no, no, no, no. Put your finger over that. You're not concentrating, you're watching me.

BUD FRAZIER: Dr. DeBakey was quite a task master. It was like working under a Marine drill sergeant. He was very tough, he expected actually much more of you than you could actually do.


His career was also not without its share of academic drama. In 1969 Dr. Denton Cooley, a heart surgeon at St. Luke's Hospital, somehow pilfered the artificial heart Dr. DeBakey had developed in a lab at Baylor, with N.I.H. funding, and implanted it in a patient at St. Luke's. DeBakey found out about the heist by reading about in the paper. He felt that Cooley had committed theft and the unethical act of using an unapproved, experimental device in order to claim a medical first (transplantation of an artificial heart into a human patient). Cooley claimed it was a desperate effort to save a patient's life.

I thought the following story quoted in The New York Times, about a trial involving Dr. Cooley, spoke volumes about his character:

Dr. Cooley recalled that a lawyer had once asked him during a trial if he considered himself the best heart surgeon in the world.

“Yes,” he replied.

“Don’t you think that’s being rather immodest?” the lawyer asked.

“Perhaps,” Dr. Cooley responded. “But remember I’m under oath.”

Dr. DeBakey's character, by contrast, is revealed by the way "he refused to testify in the litigation that followed; he did not want his rival to be found guilty. 'Much as I regretted what he did,' Dr. DeBakey said, 'I didn’t think vengeance would solve anything.' ”

Very often when we think of someone who is faraway or who has passed away, their words come back to us. We can hear their voices in our minds and hearts, and it's these memories that evoke the person's presence and spirit. Here are some more of DeBakey's own words:

On his work: "I like my work, very much. I like it so much that I don't want to do anything else."

and..."I guess it's the same gratification an artist gets from painting a beautiful painting, a poet gets from writing a beautiful poem."

On faith and God: "Practicing Christian physicians do not necessarily kneel and pray as they administer to their patients. It is, rather, a matter of communing with God on a continuous basis. God guides us; we are his instruments."

Requiescat in pacem, Michel Dabaghi. Millions of people for years to come will owe their lives and lessons to you.

Photo: a cedar of Lebanon

Sources:

CBS News article 7/12/08: http://www.cbsnews.com/stories/2008/07/12/health/main4255275.shtml

Wikipedia: http://en.wikipedia.org/wiki/Michael_E._DeBakey

Baylor College of Medicine website: http://www.bcm.edu/news/packages/medinnovations.cfm

Transcript of Nova program "Electric Heart": http://www.pbs.org/wgbh/nova/transcripts/2617eheart.html

NY Times article on the Cooley/DeBakey rift: http://www.nytimes.com/2007/11/27/health/27docs.html?ex=1353819600&en=bcf0c7c7d8ea289e&ei=5124&partner=permalink&exprod=permalink

Inspired: The Breath of God - Conversations with Gifted People about their Faith and Inspiration, collected by Joanna Laufer and Kenneth S. Lewis (currently out-of-print)

Sign Here, Please

I have a confession to make.

I don't believe in informed consent.

Or rather, I believe that informed consent is occasionally possible, but that true informed consent is rare.

Even if I spend an HOUR talking to a patient about every possible common effect or complication of every drug and piece of equipment I use, maybe even if I get to the UNcommon things, I don't think I can adequately convey the amount of information that would enable anyone except another trained anesthesiologist to give me genuine, fully informed consent for an anesthetic. Fairly well informed consent I can get, probably, but not fully informed.

If an orthopedic surgeon spends a very long time explaining the ins and outs of, say, a radial head resection to me, I'll get a general idea, perhaps even a very good idea, of what I'm in for if I need the surgery, but I won't have his or her years of experience witnessing and doing the procedure and dealing with all the possible events it might generate. Even with medical school under my belt and some surgical experience, the intimate knowledge that comes from hard-earned expertise will never be mine.

That's why I don't want my orthopedist to just list statistics about possible complications for me. I want advice. I want medical guidance in light of the knowledge and education I lack. I want HELP making the decision that's the best fit for me and my problem.

For this reason, just as I believe a paternalistic approach to doctor-patient communication is wrong, I believe the "independent choice" model, in which patients are given information but not recommendations, is wrong: a disservice and a failure to provide the patient care we took an oath to provide when we all promised we'd try to be good doctors. I favor a more collaborative approach that allows me to put my expertise to the service of another and also preserves my patient's right to make decisions in as informed a way as possible.

I do not think of patients as customers. I think of patients as patients. Customers buy things they want for themselves. Patients seek help that they lack the knowledge, skill, and expertise to provide for themselves, and often that help comes in the form of experiences they really don't want but which might be necessary in order to recuperate or preserve their health and safety. That is, unless they are truly unwilling to experience those unwanted things and would literally rather die than undergo those experiences. If someone is competent to come to that decision, I am duty-bound to respect his or her wishes. But if patients are willing to let me offer the help I know how to offer, then sometimes I have to put patient safety ahead of patient comfort, though I always strive for both.

I studied basic principles of medical ethics in med school. There are four principles written about extensively by Beauchamp and Childress that have given medical practitioners a common language to use in discourse and practice, regardless of differences in cultural background, value systems, and religious or moral views. These principles or ethical goals are

• Patient autonomy
• Beneficence
• Nonmaleficence and
• Justice.

I never think much about the way I am confronted daily with small ethics issues, but lately I've been noticing that they're actually a pretty prominent part of my practice of medicine, especially the first principle: patient autonomy. My job actually entails taking away people's autonomy entirely, at least temporarily; once they are anesthetized, they have little control over the treatment decisions I make. But usually there's a chance to discuss the important points beforehand, and during those discussions I try to respect patient autonomy while also expressing my preferences and plans.

An example: a woman whose preop history I was recording asked me if she would be given the drug Versed (generic name: midazolam) without being told before her surgery. I told her that I personally never administer it without making sure a patient wants to receive it and knows of possible effects such as memory loss of events around the time of the drug's administration. Very rarely, patients report experiences with this drug that are so awful for them that there's even a website on which hundreds of vitriolic comments (including some exceedingly ignorant and bigoted ones) against anesthesiologists have been posted, one even comparing us all to people who commit date-rape. While I try to be as thorough as I can about explaining my anesthetic plan, I do think it's unrealistic, not always useful, and often downright impractical for us to give patients a full run-down on every single drug we administer as part of the anesthetic.

Another example: a morbidly obese pregnant woman needed to have a cesarean delivery for a fetus in breech position. She adamantly refused to have an IV inserted. My colleague informed her that he absolutely could not and would not provide anesthetic care without IV access and would have to have her sign a form stating she was refusing care and aware of the risks. She eventually agreed to an I.V. He also tried to explain the relative danger of a general anesthetic versus a spinal or epidural for the procedure, but she would have none of it - she wanted a general anesthetic, no regional anesthetic, but she wanted to be woken up as soon as the baby was pulled out of her body and she wanted her husband to cut the cord. He had to tell her that this plan just would not be possible. Sometimes full patient autonomy is not only impossible but also inadvisable.

Another: a mother at Children's once told me that under no circumstances did she want a breathing tube inserted in her child. I told her that we would have no choice but to cancel, or at least postpone, the surgery. An un-secured airway was just not an option for the procedure; proceeding without one would have constituted malpractice. She then relented a little and began to ask questions - why the tube was necessary, what it meant for her child, whether her child would experience discomfort from it. I answered all her questions as thoughtfully as I could, and in the end she gave us permission to take care of her child.

One more: a former nurse refused to give consent for a general anesthetic for a procedure we most commonly performed under general. She told me she would cancel and go home if she couldn't have a spinal. I told her I could safely provide a spinal anesthetic but was professionally and ethically obligated to inform her of the possible complications before we proceeded. When I started explaining these, she was irritated at first, saying, "The other anesthesiologist I talked to in the preop clinic didn't tell me any of this!" In the end, though, with some investment in a thorough conversation, she felt reassured, and happy that I respected her wishes despite the fact that it wasn't the usual m.o. at our institution for her surgery.

I'll listen intently to what's important to my patients, and I'll do everything in my power to provide the experience they want if I can do so safely. I won't force a patient to submit to something against his or her will. But I won't practice bad medicine against my will either. My patients' safety matters too much.

L.F. Eason, You're My Hero

L.F. Eason III, former director of the North Carolina Standards Laboratory, resigned rather than lower a flag to honor the late Jesse Helms. Here are some excerpts from his NPR interview (on today's All Things Considered) that made me admire the way he stood up for his convictions:

"I gave the option of either not putting the flags up or to put them at full staff...I didn't feel that I could support anyone who had voted against every civil rights act that came before him and filibustered the Martin Luther King holiday...yes, the bricks and mortar are the state's, the flag is the state's flag, but I feel that everything that comes from that lab, good or bad, I am responsible for...I said, 'If I can't take them down, I can't work there,' so I agreed to take retirement..."

"...I'm a North Carolina native. I love this state. I feel very strongly that the amount of racism, segregation, and all that we have in this state wouldn't be nearly what it is today if it hadn't been for Jesse Helms...The first time he was elected, I was still in high school, and a good friend of mine just dropped to his knees as soon as he saw me and said, 'Yessir, Massuh, I be pickin' your cotton now, 'cause Mister Jesse's in office.' "

"What have you heard from the folks you worked with...especially the people who disagreed with you?"

"Well, so far the nominations for president are balancing out the death threats...From my counterparts in other states, in other countries, the response has been a hundred per cent supportive...People have said this is a brave thing. I have to agree with my detractors here: it's not brave. It was a very safe decision for me at this point in my life."

That may happen to be true, but it's still much easier for good people to stand by and do nothing than to go against the grain in order to uphold their own convictions.

The Charlotte Observer notes that Eason wrote the following to North Carolina Governor Mike Easley and Agriculture Commissioner Steve Troxler: “I … understand that my decision is not acceptable. You cannot ignore that fact. There is the law, but there is also a higher law I must follow as a matter of conscience.”

Thank you, Mr. Eason, for not obeying orders even when it would have been much simpler to do so. Some points will always be worth making.

________________________________________________________

Thanks to Big Ass Belle for this possible contact information for those who want to express support of / solidarity with Mr. Eason:

L.F. Eason III
c/o:The Standards Laboratory
4040 District Drive
Raleigh, NC 27607

Or comment on a piece in the Huffington Post at this link:
http://www.huffingtonpost.com/greg-mitchell/american-hero-worker-orde_b_111701.html